1. The nurse is assessing an ischial pressure ulcer on a client....

Question Answered step-by-step 1. The nurse is assessing an ischial pressure ulcer on a client…. 1. The nurse is assessing an ischial pressure ulcer on a client. Objective data reveals an ulcer that is 3 cm x 2 cm and involves partial thickness loss of the epidermis. The nurse also notes an area of redness around the pressure ulcer. What would the nurse document for this wound? a. A stage I pressure ulcer with surrounding erythema.b. A stage II pressure ulcer with surrounding erythema.c. A stage III pressure ulcer with surrounding erythema.b. A stage IV pressure ulcer with undermining. 2. A client who is moved to the hospital bed following throat surgery is ordered to receive continuous tube feeding through a small-bore nasogastric tube. Following placement of the tube which nursing action would the nurse initiate to ensure correct placement of the tube? a. Measure the gastric aspirate pHb. Obtain an order for a radiographic examination of the tubec. Auscultate the bowel soundsd. Measure the amount of residual in the tube. 3. A client is admitted for treatment of poorly healing infected leg ulcers. What is the importance of obtaining a client’s nutritional history? a. The client’s food initiate will likely be decreased because of the illnessb. Clients eating habits are usually unsatisfactory to sustain overall healthc. Poor nutrition may cause an ulcerd. wound healing and infection prevention are directly affected by poor nutrition. 4. Which of the following is a beneficial effect of fevers? a. imbalance of fluid and electrolytesb. destruction of disease-causing microorganismsc. increased fatigued. decreased response by the immune system 5. A client was admitted to a medical-surgical unit with a medical diagnosis of influenza. what type of isolation precautions are appropriate for this client? a. droplet precautionsb. contact precautionsc. contact precaution with bleachd. Airborne precautions 6. In a nurse shift of working with the same client and care plan the nurse notes no improvement in the condition or size of the client’s sickness. what phase of the nursing process involves care plan revision?a. evaluationb. implementationc. diagnosisd. assessment 7. which of the following assessment tools can be used to specifically identify clients at risk for pressure ulcer development a. Mini-mental state examinationb. Morse fall scalec. Braden scaled. 24-hour diet recall Health Science Science Nursing FUNDS NR224 Share QuestionEmailCopy link Comments (0)